Weil Osteotomy, North Bristol National Health Service Information Booklet

This document might mislead patients. Exerpts from this booklet are repeated in bold italics.

“You have been selected for a Weil Osteotomy”. This is patronising and unfair because the availability of alternate surgery is not mentioned. Why is it not said that the Weil osteotomy involves cutting through a perfectly normal, functional bone anticipating that it will eventually unite?

“If the main problem, or an important part of it, is that one of the metatarsals is too long relative to the others or points too far downwards the Weil Osteotomy would usually be advised. “  There is little reasoning here.  The irrationality of the “metatarsal parabola” concept has been addressed elsewhere on this web-site.  The other commonly bandied explanation is that the metatarsal head has “dropped”.  (As phrased here, “points too far downwards”)  This is also nonsensical, since during standing the metatarsal heads are all in contact with the floor surface.  They cannot “drop”.

“For some the joint at the toes base (“metatarso-phalangeal joint”) is so tight and stiff that it cannot easily be straightened.  A Weil Osteotomy of the metatarsal will relax the joint sufficiently to allow it to straighten and heal without excessive pressure”.  Is it claimed that the cause of “claw tows” and similar are caused by “tight joints”? The is no evidence  of any type for that. This is simply wild, misleading, speculation. There is no evidence whatever that the Weil Osteotomy “relaxes the joint”.  Indeed one of its claimed benefits is a tightening of the plantar plate.

“Will I have to go to sleep (general anaesthetic)?”

Alternatives suggested in this brochure are an “injection in the back, leg or around the ankle can be done to make the foot numb while you are awake”.  Presumably these alternatives are a spinal or epidural anaesthetic, sciatic block or local infiltration around the ankle. Why are they not described as such? Patients are usually well informed about these terms.

All these listed forms of regional anaesthesia have the disadvantage of being long acting.  All these are unpleasent when administered. with a variety of possible complications. “Ankle block” is notably painful.What is important in foot surgery, and particularly in the elderly, is that the anaesthetic should be reversed promptly, so as not to leave a dangerously insensate foot.  None of these procedures allow that, whereas there are others (not listed) which allow prompt return of sensation.

Regional Anaesthetic block is the management of choice. It has none of the complications or unpleasantness of general anaesthesia, and -not unimportant – is easily reversed allowing safe, tactile, walking. The later has great importance for the safety of the elderly.

What will happen afterwards?  “For the first two weeks you should avoid walking if possible and only put your weight to the heel”. Difficult and dangerous in the elderly.

Risks.  “About 8 in 10 people have an excellent result from the Weil Osteotomy.  Up to 2 in 10 do not for a number of reasons”. Much fairer to the patient is to say that “About two in ten have a poor result”. [The Weil Osteotomy possibly has a more than 20% chance of failure, depending upon various reviews.]  Is that acceptable that that the procedure fails for one in every five persons?  This leaflet then goes on to give excuses for failure.  All these appear fatuous.

 “The foot tends to swell up quite a lot after surgery.  Swelling is part of your body’s natural response to any injury and surgery is no exception.  In addition your foot is at the bottom of your body so fluid tends to collect in the tissues and cause swelling.  People vary in how quickly the swelling disappears after the operation and 6 months is not all that unusual.  Provided you are not having undue pain and inflammation there is probably nothing to worry about and you can afford to give it time”.  To imply that swelling of the lower limb should not be of concern is not correct.  Swelling of the lower limbs, of whatever cause, is undesirable. The reasons will not be listed here. There are good reasons to believe that anyone who has swelling of the lower limb three days after surgery should be treated with an elasticised stocking.

Another complication baldly listed is deep vein thrombosis and pulmonary embolism.  Is it not imperative that patients should be warned in advance of signs and symptoms of this condition?  Knowing of its existance, and seeking prompt medical attention should  any symptoms pointing to the possibility, is mandatory.

Post surgical swelling in the lower limb.

An answer to queries under “comments”, 11 November 2011.

1. X-rays are very limited in what they show, and very “observer dependent”, which means some are better than others in interpreting what is shown. Even complex visualization, such as MRI will not necessarily give answers. Diagnosis depends upon a number of skills, such as the history, clinical examination, and other factors such as experience and intuition. All these qualities need to be combined and correlated if high diagnostic accuracy is sought. Matters often go very wrong when the patient takes the attitude of believing (sometimes insisting) that “all will be shown” by an x-ray and similar. Indeed x-rays can show apparent abnormalities, “red herrings”, and mislead completely. In spinal surgery one of the most dangerous instruments is the MRI. It shows so much that apparent abnormalities can mislead the treatment in a hazardous way.  Therefore it is not possible to say “no fault is found”. All that can be said is that that observer found no abnormality.
2. Swelling in the lower limbs is often treated by diuretics, which dehydrate the individual.  That means giving almost every cell in the body a dose of an abnormal chemical. There are other hazards of dehydration, which I will not labour here. Far better is to treat the parts which need treatment. A good start would be to try elasticised stockings. If the problem is a hydrodynamic one the stockings will work.
3. Another benefit of elasticised stockings is that an undiagnosed or preventable deep vein thrombosis can be treated with (properly designed and fitted) elasticised stockings.
4. If lower limb swelling is also present in the uninjured limb, then an entirely different group of diagnoses must be considered.
5. But it must be remembered that infection and problems with the blood vessels also produce swelling in the lower limbs. An entirely normal limb can be made to swell by inactivating it by walking with crutches.
6. If your swelling is localize to only some of the hardware, then local infection must be considered.
7. At this stage a few days wait is unlikely to make any difference. Rather use the time to ensure an accurate diagnosis and reduce the swelling with stockings. In any event you should use the stockings from immediately after the surgery (see earlier posts).
8. No surgery is entirely exempt from complications. However if the tissues are handled gently the chance of infection are considerably reduced. See earlier page on “Painless surgery”. There is a direct correlation between painful surgery (and for that men injurious surgery) and complications.
9. Discuss the method of removal with your surgeon. It is possible to do “subcutaneous” removal of plates and screws through small puncture wounds.